by: Natsayi Chimbindi and Till Bärnighausen,                  Jul 2010

The project on Researching Equity in Access to Healthcare (REACH) is a multi-site study that was conducted in the public sector health care system in four provinces in South Africa. The study was conducted in four sub-districts — two rural (Hlabisa (KwaZulu Natal) and Bushbuckridge (Limpopo)) and two urban (City of Johannesburg (Gauteng) and Mitchell’s Plain (Cape Town)) in collaboration with four South African research institutions (University of Cape Town (Health Economics Unit), University of the Witwatersrand (Centre for Health Policy), the Rural AIDS and Development Research Programme (RADAR) in Bushbuckridge and the Africa Centre for Health and Population Studies together with McMaster University in Canada. REACH aims to develop a better understanding of the barriers to obtaining health care faced by people living in South Africa. Data was collected to understand patient access to care for three conditions requiring health care; maternal health (focusing on emergency and specialised needs at the time of delivery), tuberculosis care (TB), and antiretroviral therapy (ART). We analysed the challenges to healthcare access experienced by those accessing ART care with respect to availability, affordability and acceptability of services.

Preliminary results from the ART data show that the cost of accessing treatment at the two rural sites (Hlabisa and Bushbuckridge) were substantially higher than at the two urban sites (Mitchell’s Plain and City of Johannesburg), largely because patients incurred larger costs in travelling to clinics at the rural sites.  Time to get to a clinic was much higher in the rural than in the urban sites, but the time spent at a clinic waiting for a health care provider was about equal in all four sites (approximately 4 hours).  Acceptability of the type of care was measured by general respect from health care providers, which was ranked highly across all sites (more than nine tenth of the patients stated that they were treated with respect by the clinic staff). However, a considerably high proportion (about two-fifths) of patients from the rural sites reported that some staff did not treat patients with sufficient respect. Affordability was measured by patients’ ability to pay for health services and a higher proportion of patients from rural sites (27% Bushbuckridge and 36% Hlabisa) compared to their urban (2% City of Johannesburg and 11% Mitchell’s Plain) counterparts borrowed money in the last month to pay for health services. Utilisation of services was quite high as measured by the high levels of self-reported dose adherence (above 90%) and appointment adherence across all sites. High levels of self-reported use of alternative health care across all sites were reported which highlights patient health-seeking belief system or patient preference of other providers of health care. Considerably greater barriers to access were experienced by ART patients in rural compared to urban primary care clinics across all dimensions — availability, acceptability and affordability. Generally, patients were satisfied with the service they received.  However, they identified a number of areas in need of improvement such as the need for shorter queues; more health workers, cleaner facilities and better patient facilities (toilets, waiting room area, etc.). A number of papers are in preparation and will be published in the coming months.